Healthcare Provider Details

I. General information

NPI: 1073841078
Provider Name (Legal Business Name): WOUND CARE STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ROCKLEDGE BLVD SUITE 109
ROCKLEDGE FL
32955-3763
US

IV. Provider business mailing address

1950 ROCKLEDGE BLVD SUITE 109
ROCKLEDGE FL
32955-3763
US

V. Phone/Fax

Practice location:
  • Phone: 321-638-0880
  • Fax: 321-638-2126
Mailing address:
  • Phone: 321-638-0880
  • Fax: 321-638-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID A SIMONSON
Title or Position: PRESIDENT
Credential: DPM
Phone: 321-638-0880